Iliac Vein Laceration Research Articles

Application of Oblique Lateral Interbody Fusion in Treatment of Lumbar Spinal Tuberculosis in Adults.

ObjectiveThe purpose of the present paper was to evaluate the safety and clinical efficacy of mini‐open retroperitoneal oblique lumbar interbody fusion (OLIF) for the treatment of lumbar spinal tuberculosis.MethodsA total of 115 patients who suffered from lumbar spinal tuberculosis from June 2014 to December 2017 were included in this research. A total of 59 patients underwent OLIF and percutaneous pedicle screw fixation (OLIF group) and 56 patients underwent the anterior‐only approach (anterior‐only group). All patients were followed up for at least 24 months. Operation time, blood loss, and rate of complications were used to assess the safety of these two techniques. The visual analog scale (VAS) and the Oswestry disability index (ODI) were used to evaluate the relief of neurological and functional symptoms. The erythrocyte sedimentation rate (ESR) and C‐reactive protein (CRP) were measured to investigate the activity and recurrence of spinal tuberculosis. The Cobb angle, the sagittal vertical axis of the spine (SVA), the pelvic tilt (PT), the sacral slope (SS), the pelvic incidence (PI), and postoperative Frankel classification were also used to assess the efficiency of the spine deformity correction and the recovery of long‐term neurological function.ResultsMost patients were successfully treated with OLIF and the anterior‐only technique and attained satisfactory clinical efficiency during the 24‐month follow‐up period. In the perioperative period, the mean operative time (154.68 ± 23.64 min, P < 0.001), the mean blood loss (110.57 ± 87.67 mL, P < 0.001), and the mean hospital stay (9.55 ± 3.62 days, P < 0.001) of the OLIF group were all significantly lower than in the anterior‐only group (172.49 ± 25.67 min, 458.56 ± 114.89 mL, and 14.89 ± 3.89 days, respectively). A total of 10 patients (16.95%) experienced complications in the OLIF group, including neurological injury, segmental artery and iliac vein lacerations, peritoneal injury, instrument failure, and infection of incisions; this rate of complications was lower than in the anterior‐only group (37.50%, P = 0.013). Regard to spinal deformity correction, the Cobb angle (9.42° ± 1.72°, P = 0.032), the SVA (2.23 ± 1.07 cm, P = 0.041), the PT (14.26° ± 2.37°, P = 0.037), and the SS (39.49° ± 2.17°, P = 0.042) of the OLIF group at last follow‐up were all significantly different when compared to the anterior‐only group (14.75° ± 2.13°, 3.48 ± 0.76 cm, 18.58° ± 1.45°, and 36.78° ± 1.96°, respectively). The VAS and the ODI of the OLIF group at 1 week postoperatively (3.15 ± 0.48, 21.85 ± 3.78, P = 0.032, 0.037) and at the last follow‐up (2.12 ± 0.35, 16.70 ± 5.25, P = 0.043, 0.035) were both lower than for the anterior‐only group (5.18 ± 0.56, 29.83 ± 5.42 and 3.67 ± 0.62, 20.68 ± 6.23). The Frankel classification was improved for both OLIF and anterior‐only patients; however, there were 35 cases (59.32%) classified as Frankel grade E in the OLIF group and 22 cases (39.29%, P = 0.021) in the anterior‐only groupConclusionThe OLIF surgical technique for single lumbar (L2–L5) spinal tuberculosis is less invasive, has lower complication rates, and is more efficient than the anterior‐only approach. However, the long‐term effects of this surgical technique still need to be explored.

Revision Surgery of Total Lumbar Disk Replacement: Review of 48 Cases.

This was a retrospective clinical review. The objective of this study was to analyze failure mechanisms after total lumbar disk replacement (TDR) and surgical revision strategies in patients with recurrent low back pain (LBP). Several reports indicate that TDR revision surgery carries a major risk and that it should not be recommended. The clinical results of posterior instrumented fusion using the prosthesis like an interbody cage have not been well analyzed. From 2003 to 2018, 48 patients with recurrent LBP after TDR underwent revision surgery. The average age was 39 years (24-61 y). The mean follow-up was 100.4 months (24.6-207.7 mo). Clinical data, self-assessment of patient satisfaction, and Oswestry Disability Index collected at each clinical control or by phone call for the older files and radiologic assessments were reviewed. The surgical revision strategy included posterior fusion in 41 patients (group A) and TDR removal and anterior fusion in 7 patients (group B), of which 6 patients had an additional posterior fixation. Facet joint osteoarthritis was associated with TDR failure in 85%. In 68% the position of the prosthesis was suboptimal. Range of motion was preserved in 25%, limited in extension in 65%, and limited in flexion in 40%. Limited range of motion and facet joint osteoarthritis were significantly related (P=0.0008). The complication rate in group B was 43% including iliac vein laceration. Preoperative and 2-year follow-up Oswestry Disability Index were 25.5 and 22.0, respectively, in group A versus 27.9 and 21.3 in group B. Posterior osteoarthritis was the principal cause of recurrent LBP in failed TDR. The anterior approach for revision carried a major vascular risk, whereas a simple posterior instrumented fusion leads to the same clinical results. Level IV.

258. Exploring perioperative complications of anterior lumber interbody fusion in patients with a history of prior abdominal surgery: a retrospective cohort study

258. Exploring perioperative complications of anterior lumber interbody fusion in patients with a history of prior abdominal surgery: a retrospective cohort study

"External Iliac Vein Laceration-A Rare Complication of Tunneled Dialysis Catheter"

Bleeding complication from Central dialysis catheter is rare. Usually it settles in short time after procedure. If patient is on antiplatelet therapy it can sometimes last for 24-48 hours and stops with pressure dressing. We report a rare case of ongoing (>96 hour post procedure) bleeding from dialysis catheter exit site and investigation revealed the cause was iliac vein laceration.

Exploring perioperative complications of anterior lumber interbody fusion in patients with a history of prior abdominal surgery: A retrospective cohort study

BACKGROUND CONTEXTAnterior lumbar interbody fusion (ALIF) exposes the anterior aspect of the spine through a retroperitoneal approach. Access to the anterior spine requires mobilization of intra-abdominal viscera/vasculature, which can become complicated as scarring and/or adhesions develop from prior abdominal surgical interventions, increasing risk of intraoperative complications. The literature suggests that “significant prior abdominal surgery” is a relative contraindication of ALIF surgery; however, there is no consensus within the literature as to what defines “major/significant” abdominal surgeries. Additionally, the association between the number of prior abdominal surgeries and perioperative complications in ALIF surgery has not been explored within the literature. PURPOSEThis study seeks to explore the association between perioperative complications of ALIF surgery and the type (major and/or minor) and number of prior abdominal surgeries. DESIGNA retrospective cohort study was performed to examine perioperative complications in ALIF patients with or without prior history of abdominal surgery. PATIENT SAMPLEAll consecutive patients undergoing ALIF with or without a history of prior abdominal surgery from 2008 to 2018 at a single tertiary center were evaluated. Patients under the age of 18, patients with spinal malignancy, or patients who had ALIF above L3 were excluded. OUTCOME MEASURESPerioperative complications included intraoperative complications during ALIF surgery and postoperative complications within 90 days of ALIF surgery. Intraoperative complications include vascular injury, ureter injury, retroperitoneal hematoma, etc. Postoperative complications include urinary tract infection, revision of abdominal scar, ileus, deep vein thrombosis, pulmonary embolism, etc. Other outcome measures include readmission within 90 days, length of ALIF surgery, and length of hospital stay. METHODSElectronic medical records of 660 patients who underwent ALIF between 2008 and 2018 were retrospectively reviewed. Patient demographics, Charleston Comorbidity Index (CCI), level of fusion, past abdominal surgical history, use of access surgeon during exposure, intraoperative, and postoperative complications were collected. Predictors of intraoperative and postoperative complications were analyzed using simple and multivariable logistic regression. Statistical analysis was performed using JMP 14.0 (SAS, Cary, NC, USA) software. RESULTSAfter controlling for age, length of ALIF, gender, multilevel ALIF, and the use of an access surgeon, there was no significant association between the type of prior abdominal surgery (major and/or minor) and intraoperative complications on multivariable logistic regression analysis (Minor: odds ratio [OR]=1.68; 95% confidence interval [CI]: 0.58–4.86 & Major: OR=1.99; 95% CI: 0.80–4.91). On multivariable logistic regression, the odds of developing an intraoperative complication increases by 52% for each additional prior abdominal surgery after adjusting for age, length of ALIF, gender, multilevel ALIF, and the use of an access surgeon (OR=1.52, 95% CI: 1.10–2.11). Iliac vein laceration was the most common intraoperative complication (n=27, 4%). Neither the type (major and/or minor) nor the number of prior abdominal surgeries were significant predictors of postoperative complications (Minor: OR=1.29; 95% CI: .72–2.31, Major: OR=1.24; 95% CI: 0.77–2.00, & Number: OR=1.03; 95% CI: .84–1.26). CONCLUSIONWith each additional prior abdominal surgery, accumulation of scarring and adhesions can likely obscure anatomical landmarks and increase the risk of developing an intraoperative complication. Therefore, the number of prior abdominal surgeries should be taken into consideration during planning and operative exposure of the anterior spine via a retroperitoneal approach.

Systemic Laparoscopic Para-Aortic Lymphadenectomy to the Left Renal Vein.

Background:No large-scale clinical study has been done to show the standard surgical boundary and efficacy of laparoscopic para-aortic lymphadenectomy (LPAL).Objectives:Therfore, this study aimed to evaluate the feasibility, efficacy, and standard surgical boundary of LPAL performed up to the left renal vein level in gynecological malignancies.Methods:Medical records of 333 patients were retrospectively reviewed. All cases had gynecologic malignancies and had an operation including LPAL by a single surgical team between November 2003 and May 2018.Results:Three hundred twenty-six patients underwent LPAL as part of their staging, restaging, or debulking surgery. Seven patients with isolated para-aortic lymph node recurrence underwent a repeat LPAL. The median age and body mass index were 54 years (range, 28–81 years) and 26.0 kg/m2 (range, 20.3–37.2 kg/m2), respectively. The median operating time was 60 minutes (range, 24–135 minutes), and the median number of harvested para-aortic lymph nodes was 12 (range, 6–49). There were 11 cases of complications: 5 of major vessel injuries (3 inferior vena cava, 1 aorta, and 1 common iliac vein), 2 lymphocysts, 2 cases of chylous ascites, a cisterna chyli rupture, and 1 case of ureteric injury. There were 2 conversions to laparotomy: 1 left common iliac vein laceration that needed to be repaired and removal of an enlarged para-aortic lymph node completely.Conclusion:It is feasible and efficient to perform LPAL to the left renal vein level for women with gynecologic malignancies by well-trained gynecologic oncology surgeons according to our suggested standard surgical boundary.

Can Navigation-assisted Surgery Help Achieve Negative Margins in Resection of Pelvic and Sacral Tumors?

Navigation-assisted resection has been proposed as a useful adjunct to resection of malignant tumors in difficult anatomic sites such as the pelvis and sacrum where it is difficult to achieve tumor-free margins. Most of these studies are case reports or small case series, but these reports have been extremely promising. Very few reports, however, have documented benefits of navigation-assisted resection in series of pelvic and sacral primary tumors. Because this technology may add time and expense to the surgical procedure, it is important to determine whether navigation provides any such benefits or simply adds cost and time to an already complex procedure. (1) What proportion of pelvic and sacral bone sarcoma resections utilizing a computer-assisted resection technique achieves negative margins? (2) What are the oncologic outcomes associated with computer-assisted resection of pelvic and sacral bone sarcomas? (3) What complications are associated with navigation-assisted resection? Between 2009 and 2015 we performed 24 navigation-assisted resections of primary tumors of the pelvis or sacrum. Of those, four were lost to followup after the 2-year postoperative visit. In one patient, however, there was a failure of navigation as a result of inadequate imaging, so nonnavigated resection was performed; the remaining 23 were accounted for and were studied here at a mean of 27 months after surgery (range, 12-52 months). During this period, we performed navigation-assisted resections in all patients presenting with a pelvis or sacral tumor; there was no selection process. No patients were treated for primary tumors in these locations without navigation during this time with the exception of the single patient in whom the navigation system failed. We retrospectively evaluated the records of these 23 patients and evaluated the margin status of these resections. We calculated the proportion of patients with local recurrence, development of metastases, and overall survival at an average 27-month followup (range, 12-52 months). We queried a longitudinally maintained surgical database for any complications and noted which, if any, could have been directly related to the use of the navigation-assisted technique. In our series, 21 of 23 patients had a negative margin resection. In all patients the bone margin was negative, but two with sacral resections had positive soft tissue margins. Six of 23 patients experienced local recurrence within the study period. Three patients died during the study period. Seventeen patients demonstrated no evidence of disease at last recorded followup. We noted three intraoperative complications: one dural tear, one iliac vein laceration, and one bladder injury. Eight patients out of 23 had wound complications resulting in operative débridement. Two patients in the series developed transient postoperative femoral nerve palsy, which we believe were caused by stretch of the femoral nerve secondary to the placement of the reference array in the pubic ramus. Navigation-assisted resection of pelvic and sacral tumors resulted in a high likelihood of negative margin resection in this series, and we observed relatively few complications related specifically to the navigation. We have no comparison group without navigation, and future studies should indeed compare navigated with nonnavigated resection approaches in these anatomic locations. We did identify a potential navigation-related complication of femoral nerve palsy in this series and suggest careful placement and observation of the reference array during the operative procedure to lessen the likelihood of this previously unreported complication. We suggest it is worthwhile to consider the use of navigation-assisted surgery in resection of tumors of the pelvis and sacrum, but further study will be needed to determine its precise impact, if any, on local recurrence and other oncologic outcomes. Level IV, therapeutic study.

Laparoendoscopic Single-site Radical Hysterectomy With Pelvic Lymphadenectomy: Initial Multi-institutional Experience for Treatment of Invasive Cervical Cancer

Study ObjectiveTo describe the feasibility, safety, and outcomes of women with stage I cervical cancer treated with laparoendoscopic single-site surgery radical hysterectomy (LESS-RH). DesignA retrospective descriptive study (Canadian Task Force classification III). SettingMultiple academic teaching hospitals. PatientsWomen with Fédération Internationale de Gynécologie et d'Obstétrique FIGO stage IA1 to IB1 cervical cancer. InterventionsLESS-RH as the primary therapy for cervical cancer performed by a gynecologic oncologist with expertise in LESS. A multichannel, single-port access device; a flexible-tipped 5-mm laparoscope; and a multifunctional instrument were used in all cases. Clinicopathologic, surgical, and perioperative outcomes were analyzed. Measurements and Main ResultsTwenty-two women were identified in whom a LESS-RH was attempted; 20 (91%) successfully underwent the procedure, including 19 in whom pelvic lymphadenectomy (PLND) was completed. Of the 2 converted procedures, 1 patient underwent 2-port laparoscopy secondary to truncal obesity, and 1 patient underwent conversion to laparotomy secondary to external iliac vein laceration during PLND. The median age and body mass index were 46 years and 23.3 kg/m2, respectively. The median number of pelvic lymph nodes removed was 22. One patient experienced an intraoperative complication, and no patient required reoperation. The margins of excision were negative. One patient with 2 positive pelvic nodes and 1 patient with microscopic parametrial disease received adjuvant chemosensitized radiation; 3 additional patients received adjuvant radiation therapy secondary to an intermediate risk for recurrence. After a median follow up of 11 months, no recurrences were detected. ConclusionLESS-RH/PLND is feasible and safe for select patients with stage I cervical cancer. Larger studies are needed to confirm whether the increased technical difficulty of this procedure justifies its use in routine gynecologic oncology practice.

Laparoscopic Lymphadenectomy for Isolated Lymph Node Recurrence in Gynecologic Malignancies

Study ObjectiveTo assess the feasibility and efficacy of laparoscopic lymphadenectomy in patients with isolated lymph node recurrences (ILNR) who underwent initial surgery for gynecologic malignancy.DesignRetrospective study (Canadian Task Force classification II-3).SettingUniversity teaching hospital.PatientsSix patients with ILNR (one cervical, four ovarian, and one peritoneal) diagnosed between March 2003 and July 2010.InterventionLaparoscopic lymphadenectomy.Measurements and Main ResultsThe median age was 59.5 years (range 24-70) and the median body mass index was 21.7 (range 21.0-24.6). There was no unplanned conversion to laparotomy. The median operating time was 337.5 minutes (range 200-400), median hemoglobin change was 0.9 g/dL (range 0.4-2.6), and median hospital stay was 8.5 days (range 5-19). The median number of harvested lymph nodes was 20 (range 5-27) and those of positive lymph nodes was 4 (range 1-24). One patient had common iliac vein laceration with complete hemostasis achieved by intracorporeal suture. Postoperative lymphedema occurred in one patient and was managed conservatively. All patients were treated with adjuvant chemotherapy following laparoscopic lymphadenectomy.ConclusionLaparoscopic lymphadenectomy in patients with an ILNR is feasible and might be an alternative therapeutic strategy. Study ObjectiveTo assess the feasibility and efficacy of laparoscopic lymphadenectomy in patients with isolated lymph node recurrences (ILNR) who underwent initial surgery for gynecologic malignancy. To assess the feasibility and efficacy of laparoscopic lymphadenectomy in patients with isolated lymph node recurrences (ILNR) who underwent initial surgery for gynecologic malignancy. DesignRetrospective study (Canadian Task Force classification II-3). Retrospective study (Canadian Task Force classification II-3). SettingUniversity teaching hospital. University teaching hospital. PatientsSix patients with ILNR (one cervical, four ovarian, and one peritoneal) diagnosed between March 2003 and July 2010. Six patients with ILNR (one cervical, four ovarian, and one peritoneal) diagnosed between March 2003 and July 2010. InterventionLaparoscopic lymphadenectomy. Laparoscopic lymphadenectomy. Measurements and Main ResultsThe median age was 59.5 years (range 24-70) and the median body mass index was 21.7 (range 21.0-24.6). There was no unplanned conversion to laparotomy. The median operating time was 337.5 minutes (range 200-400), median hemoglobin change was 0.9 g/dL (range 0.4-2.6), and median hospital stay was 8.5 days (range 5-19). The median number of harvested lymph nodes was 20 (range 5-27) and those of positive lymph nodes was 4 (range 1-24). One patient had common iliac vein laceration with complete hemostasis achieved by intracorporeal suture. Postoperative lymphedema occurred in one patient and was managed conservatively. All patients were treated with adjuvant chemotherapy following laparoscopic lymphadenectomy. The median age was 59.5 years (range 24-70) and the median body mass index was 21.7 (range 21.0-24.6). There was no unplanned conversion to laparotomy. The median operating time was 337.5 minutes (range 200-400), median hemoglobin change was 0.9 g/dL (range 0.4-2.6), and median hospital stay was 8.5 days (range 5-19). The median number of harvested lymph nodes was 20 (range 5-27) and those of positive lymph nodes was 4 (range 1-24). One patient had common iliac vein laceration with complete hemostasis achieved by intracorporeal suture. Postoperative lymphedema occurred in one patient and was managed conservatively. All patients were treated with adjuvant chemotherapy following laparoscopic lymphadenectomy. ConclusionLaparoscopic lymphadenectomy in patients with an ILNR is feasible and might be an alternative therapeutic strategy. Laparoscopic lymphadenectomy in patients with an ILNR is feasible and might be an alternative therapeutic strategy.

Laparoscopic Lymphadenectomy for Isolated Lymph Node Recurrence in Gynecologic Malignancies

Study ObjectiveTo assess the feasibility and efficacy of laparoscopic lymphadenectomy in patients with isolated lymph node recurrences (ILNR) who underwent initial surgery because of gynecologic malignancy. DesignRetrospective study (Canadian Task Force classification II-3). SettingUniversity teaching hospital. PatientsSix patients with ILNR (1 cervical, 4 ovarian, and 1 peritoneal) diagnosed between March 2003 and July 2010. InterventionLaparoscopic lymphadenectomy. Measurements and Main ResultsMedian (range) patient age was 59.5 (24–70) years, and body mass index was 21.7 (21.0–24.6). There was no unplanned conversion to laparotomy. Operating time was 337.5 (200–400) minutes, hemoglobin change was 0.9 (0.4–2.6) g/dL, and hospital stay was 8.5 (5–19) days. The number of harvested lymph nodes was 20 (5–27), and of positive lymph nodes was 4 (1–24). One patient had common iliac vein laceration, with complete hemostasis achieved using intracorporeal suture. Postoperative lymphedema occurred in 1 patient, and was managed conservatively. All patients received adjuvant chemotherapy after laparoscopic lymphadenectomy. ConclusionLaparoscopic lymphadenectomy in patients with ILNR is feasible and might be an alternative therapeutic strategy.

Colonic, ureteral, and vascular injuries secondary to stick impalement in a dog

To report the surgical repair, case management, and outcome of a dog with sepsis and severe intraabdominal trauma secondary to a penetrating stick injury. A 1.5-year-old, spayed female, mixed-breed dog was presented to the emergency service after incurring a small laceration on the medial aspect of the left pelvic limb while running in the woods. The wound was surgically explored and a primary closure achieved. The patient was discharged the same day with oral antimicrobial therapy. The following morning the dog was represented to the emergency service for acute vomiting. Abdominal radiographs were performed and demonstrated loss of serosal detail and pneumoperitoneum. An emergency celiotomy was performed and revealed distal colonic perforation, left ureteral laceration, and lacerations of the left common iliac vein. Ureteronephrectomy, as well as primary closure of the distal colonic perforation and left common iliac vein lacerations, were performed. The patient recovered and was ultimately discharged from the hospital 5 days later. Follow-up 1 year later revealed no significant physical exam or biochemical abnormalities. A seemingly benign penetrating stick injury initially deemed to be superficial in nature was later demonstrated to have resulted in sepsis following severe intraabdominal trauma that included lacerations of the distal colon, left ureter, and left common iliac vein in a dog. Successful surgical management and intensive care led to a full recovery without any residual impairment noted a year later.

Laceration of the Iliac Vein in a Patient with a Femoral Catheter for Hemodialysis

Although catheters are an ideal therapeutic treatment for all patients who need hemodialysis, their placement, use may be followed by certain complications. We present a case of iliac vein lacerations in the projection of the tip of a femoral catheter for hemodialysis in a 55-year-old patient.

Complications of Laparoscopic Radical Hysterectomy and Pelvic Lymphadenectomy-Experience of 117 Patients

To describe the combined surgical technique of laparoscopic radical hysterectomy and pelvic lymphadenectomy (LRH + LPL) for cervical cancers and summarize our experiences in prevention and treatment of complications, so as to provide strategies to prevent and appropriately manage the complications that may occur during these procedures. A retrospective study was conducted on LRH + LPL in 117 cases of cervical cancer with International Federation of Gynecology and Obstetrics stages Ib (n = 96) and II a (n = 21) from August 1998 to December 2006. The intraoperative and postoperative complications were analyzed. The overall conversion rate was 1.7% (2/117). Four patients had vessel injuries, 3 of which were treated laparoscopically. One patient had a common iliac vein laceration that could not be controlled laparoscopically after failing to deal with the injured branch of common iliac vein. Cystotomy occurred in 5 patients. One case of stage IIa with a bladder laceration longer than 3 cm was converted to laparotomy during the early stages of the learning curve. The remaining 4 were managed laparoscopically. Postoperative complications occurred in 38.5% (n = 45) of the patients, including 38 patients with urinary retention who exhibited complete resolution within 6 months by intermittent training and catheterization, 4 with lymphocyst who underwent conservation treatment, 1 with ureteral fistula that was treated by cystoscopic placement of double-J ureteral stents, 1 with mild adynamic bowel obstruction who received conservative management, and 1 with vesicovaginal fistula that was closed by conservative treatment. With the continuous skilled laparoscopic technology, mastering the tips of prevention, and treatment of complications, LRH + LPL will be widely performed in the future.

Perioperative outcomes of anterior lumbar surgery in obese versus non-obese patients

Background context Anterior lumbar surgery is a common procedure for anterior lumbar interbody fusion and disc replacement but the impact of obesity on this procedure has not been determined. Purpose To assess the perioperative outcomes of anterior retroperitoneal lumbar surgery in obese versus non-obese patients. Study design/setting Prospective review of patients with anterior retroperitoneal lumbar disc procedures Patient sample Seventy-four patients with anterior retroperitoneal lumbar disc procedures performed were evaluated. Outcome measures Access-related parameters included tissue depth (skin-to-fascia and fascia-to-spine depths), length of incision, estimated blood loss during the anterior procedure, the duration of the anterior exposure, and the duration of the entire anterior procedure. Outcome measures included complications attributable to the anterior procedure, analgesic use, length of time to ambulation, and length of hospitalization. Methods Seventy-four anterior retroperitoneal lumbar disc procedures were prospectively analyzed. Patient age, sex, body mass index, comorbidities, diagnosis, and operative parameters were collected. Access-related parameters and outcome measures were compared between obese and non-obese patients. Obesity was defined as body mass index greater than or equal to 30. Results There were 35 males and 39 females. Mean age was 46.6 years. The main diagnosis (63.5%) was discogenic back pain. Forty-one (55%) patients were non-obese and 33 were obese. The two patient groups were comparable in terms of age, sex, diagnosis, mean number of anterior levels operated, and previous abdominal surgery (all p>.05). In obese patients, there were two iliac vein lacerations (major complication rate, 6.1%), one superficial infection, and one urinary tract infection (minor complication rate, 6.1%). In non-obese patients, there were two iliac vein lacerations, one intestinal serosal tear (major complication rate, 7.3%), and two urinary tract infections (minor complication rate, 4.9%). There was no significant difference in the complication rates between obese and non-obese patients (p=.6). Obese patients have significantly longer duration of anterior exposure, duration of entire anterior surgery, longer length of anterior incision, and more depth from skin to fascia and from fascia to spine compared with non-obese patients. However, obesity does not affect blood loss, analgesic use, length of time to ambulation, and length of hospitalization. Conclusion Perioperative outcomes in obese and non-obese patients were comparable and obesity is not related to an increased risk of morbidity in anterior lumbar surgery.

Acetabular Fractures: Review of 50 Consecutive Cases

The outcome of management of 50 consecutive cases (43 males, 7 females, mean age 36.2 years) of acetabular fractures (AF) managed by the authors over a 15 year period are described. Twenty five cases were managed conservatively with bed rest, traction for 1 to 2 weeks and mobilisation with crutches nonweight bearing for at least three weeks. For those who had surgery, the operative approach consisted of non-extensile Kocher-Langenbeck (24 cases) and ilioinguinal in 1 patient. The indications for surgery included any of the following: displacement > 2mm, intra-articular fragment, posterior dislocation or luxation of femoral head and insufficient roof arc for further reconstructive surgery. The main pre-operative complication was sciatic nerve palsy (4 cases). Post-operative complications were uncommon: infected haematoma, common iliac vein laceration, heterotopic ossification, 1 each. It was observed that automobile accident (RTA) was the main aetiologic factor (86%), and males outnumber females in a ratio of 8.5:1. Conservative management proved effective for undisplaced AF, and a non-extensile operative procedure resulted in excellent reduction and reduced morbidity in severely displaced AF. Keywords : acetabular fracture, operative management, acetabular fracture Nigeria Journal of Orthopaedics and Trauma Vol. 7 (2) 2008: pp. 40-44

Revision Lumbar Arthrodesis for the Treatment of Lumbar Cage Pseudoarthrosis: Complications

A study documenting major complications encountered in revision procedures for lumbar cage pseudoarthrosis. To document the perioperative complications associated with revision surgery for threaded cylindrical cage pseudoarthrosis. Pseudoarthrosis after cylindrical cage placement manifests as persistent or recurrent pain and disability after surgery. Revision strategies include isolated posterior stabilization and posterior bone grafting, versus circumferential revision where an attempt is made to remove the cages anteriorly, followed by posterior stabilization and fusion. Potential complications associated with these revision procedures have not been adequately documented in the past. Forty-seven consecutive patients with the diagnosis of cylindrical cage pseudoarthrosis were surgically treated with either a circumferential revision (AP) or an isolated posterior instrumented fusion (P). All intraoperative and postoperative complications were documented. Radiographic interbody fusion rates and preoperative and postoperative visual analog scale (VAS) scores were documented. Three of the AP patients, all with anterior cage placement at L5-S1, had iliac vein lacerations requiring repair. A fourth patient had a ureteral injury requiring subsequent nephrectomy. Three patients who underwent circumferential revision and 2 patients who had an isolated posterior procedure had postoperative complications, including 2 infections (1 AP and 1 P), 1 radiculopathy (P), and 2 patients with prolonged ileus (both AP). There was a statistically significant decrease in overall VAS scores postoperatively for the 2 groups using the paired t test (P<0.0001). There was no difference in either the preoperative (P=0.22) or 2-year postoperative (P=0.30) VAS scores between the AP and P groups [rank-sum (Mann-Whitney) t tests]. Interbody fusion was achieved in 79% (30 of 38 levels) in the AP group. The interbody fusion rate was 37% (8 of 22) for the P group. Circumferential revision including cage removal, structural allograft placement, and posterior stabilization is associated with increased perioperative complications. Although an anterior approach showed increased interbody fusion rates, this technique did not lead to more superior clinical outcomes based on VAS scores. It remains to be shown by larger prospective studies if there is a true difference in outcome between these 2 groups that will justify the increased perioperative morbidity associated with attempted cage removal.

Anterior Retroperitoneal Lumbosacral Spine Exposure: Operative Technique and Results

We review our two-team operative technique and results of anterior retroperitoneal lumbosacral spine exposure for diskectomy, partial corpectomy, and spinal instrumentation. Seventy-two patients with lumbar spondylosis and associated symptomatic radiculopathy had this exposure between January 1, 2000 and January 1, 2002. A single disc space was isolated in 54 patients. Multilevel exposure was achieved in 18 patients. Main outcome measures included intra- and postoperative complications, blood transfusion requirements, duration of ileus, incidence of erectile/sexual dysfunction, and length of hospital stay. A single small bowel enterotomy and iliac vein laceration, both repaired primarily, were the only intraoperative complications. Perioperative blood transfusions were required in 13 patients (18%). Mean length of postoperative ileus was 3.5 days and average length of hospital stay was 5 days. Postoperative complications occurred in 7 patients (9.7%). These included erectile dysfunction (2), transient unilateral lower extremity paresis (1), acute acalculous cholecystitis (1), femoral vein thrombosis (1), pneumonia (1), and acute myocardial infarction (1). There were no genitourinary or other major vascular injuries. A two-team approach for lumbosacral spine instrumentation via anterior retroperitoneal exposure capitalizes on unique specialty-specific surgical skills. This paradigm facilitates safe lumbosacral spine surgery and major perioperative complications are rare.

Revision lumbar arthrodesis for the treatment of cylindrical cage pseudarthrosis: perioperative complications and pitfalls

James D. Schwender, MD, Francis Denis, MD, Timothy A. Garvey, MD, John E. Lohnstein, MD, James W. Ogilvie, MD, Joseph H. Perra, MD, Manuel R. Pinto, MD, Ensor E. Transfeldt, MD, Robert B. Wood, MD, Minneapolis, MN, USAIntroduction: The revision of symptomatic cage pseudarthrosis can be performed by either posterior stabilization alone or circumferential revision including anterior cage removal and anteroposterior (AP) stabilization. Inherent risks associated with revision anterior surgery are numerous. However, posterior surgery alone does not directly address the pseudarthrosis, and pain may remain in spite of solid posterior arthrodesis if the fibrous nonunion does not heal. Although an anterior bony pseudarthrosis has predictable healing with posterior stabilization, there is no information to date concerning what of this study is to identify and describe the perioperative complications associated with revision surgery for the treatment of cage pseudarthrosis.Methods: The current study addresses perioperative complications in 29 consecutive patients who underwent revision surgery for lumbar interbody cage pseudarthrosis.Results: The primary diagnosis for the index surgery was disc degeneration (86%) or spondylolisthesis (14%). Placement of the cages was originally achieved by means of anterior open technique in 85% of the cases. Time interval between the index surgery and the revision ranged from 6 to 81 months (median, 20 months). AP revision was performed in 17 patients (59%), 11 patients (38%) underwent posterior stabilization alone and 1 patient underwent an anterior alone approach. Pedicle screw instrumentation was used for posterior stabilization in all patients. Pseudarthrosis was confirmed intraoperatively in all patients. Twenty-nine cages were removed in 17 patients (20 from L5–S1; 4 from L4–L5; 1 each from L1–2, L2–3, L3–4). Two-thirds (8 of 12) of the cages encountered at L4–L5 were deemed impossible to remove because of the risk of vascular injury, whereas only 20% (5 of 25) at L5–S1 were not removed.Typically, it was found to be more difficult to remove the right-sided cage at L4–5 (three left, five right not removed), whereas at L5–S1 the left side was found to be more difficult (four left, one right not removed). Three of the AP patients (18%), all with anterior cage placement at L5–S1, had iliac vein lacerations requiring repair. All three patients remained hemodynamically stable, and surgery was completed with estimated blood loss of 600 cc, 1,400 cc and 2,300 cc. A fourth patient had a ureter injury requiring subsequent nephrectomy. No neurologic sequelae were encountered with anterior cage removal in those cases where cage placement was originally from the posterior approach. No other intraoperative complications were identified in the AP group, and no intraoperative complications were identified in the posterior only group. Three AP patients (18%) and two posterior alone patients (17%) had postoperative complications, including two infections (one AP, one posterior alone), one radiculopathy (posterior alone) and two patients with prolonged ilius (both AP). As expected, AP revision compared with the one-sided revisions resulted in increased operative time (477 minutes and 222 minutes, respectively), blood loss (1,070 cc and 477 cc, respectively) and days of hospitalization (6 and 4, respectively).Conclusions: Circumferential revision, including cage removal and posterior stabilization, is associated with increased perioperative complications. Great trepidation should be used when planning cage removal from the L4–5 level, because of our finding that 80% of such cages were impossible to remove without excessive risk. Operative time, hospitalization and blood loss are all increased with circumferential revisions. It remains to be answered by this ongoing prospective study if there exists a difference in clinical and patient outcome measures between these two groups that will justify the increased perioperative morbidity associated with attempted cage removal.

Comparison of insufflation vs retractional technique for laparoscopic-assisted intervertebral fusion of the lumbar spine.

Laparoscopic transperitoneal fusion of the L5-S1 spinal interspace has become a common procedure. Retroperitoneal retraction and laparoscopic instrumentation without insufflation also allows visualization of the upper lumbar spaces, but this procedure is much more difficult to accomplish. We review and compare our results using each of these techniques for the treatment of mechanical instability and chronic back pain. A total of 35 selected patients underwent intervertebral fusion between February 1996 and August 1998. Their mean age was 48 years. There were 22 female and 13 male patients. Standard CO2 insufflation was used in 10 patients with L5-S1 fusions. Retractional gasless technique was used in nine patients with fusions at L5-S1, 16 patients at L4-L5, one patient at L3-L4, three patients at L2-3, and one patient at L1-L2. Thus, we performed a total of 40 lumbar fusions in 35 patients. In the 19 patients with the gasless technique, a balloon dissector and retractor facilitated the retroperitoneal exposure. Seven of these 19 patients were converted to open procedures, most commonly due to lacerations of the peritoneal lining that prohibited visualization. None of the L5-S1 patients with insufflation were converted to open. Mean operative time in the insufflated patients was 152 min vs 181 min for the retractional technique. There were seven complications in the transperitoneal group: one fusion device migration, one postoperative UTI, one intracerebral hemorrhage, one severe postoperative pancreatitis, and three iliac vein lacerations. There were 16 complications in the retroperitoneal group: one deep vein thromboses, one serosal bowel injury, one small tear in the spleen, one cage migration, one postoperative pulmonary atelectasis, one postoperative hydrocele, four postoperative ileus, and six peritoneal tears. The mean postoperative stay was three days for both groups. There were no deaths. The L5-S1 interspace is best approached transperitoneally for anterior fusion. Although the retroperitoneal retractional technique is much more difficult and has a longer and steeper learning curve, it does allow laparoscopic anterior fusion of the upper lumbar spine.

Is laparoscopic approach to lumbar spine fusion worthwhile?

Background: Laparoscopic lumbar spine fusion has been recently described. The aim of this study is to evaluate the safety and efficacy of this procedure for single- and multiple-level degenerative disc disease.Methods: Twenty-four consecutive laparoscopic interbody lumbar fusions were evaluated prospectively (18 single-level were compared with 6 multiple-level procedures). Results of the laparoscopic multiple-level procedures were further compared with 12 open multiple-level operations.Results: Twenty procedures were completed laparoscopically. The conversions were related to iliac vein lacerations (3 cases) and a mesenteric tear. Single-level cases had lower morbidity (22% versus 83%), shorter hospital stay (2 versus 10 days), and higher fusion rate (88% versus 50%) than multiple-level procedures. Overall results in the latter group were worse than in the matched open group.Conclusions: Laparoscopic single-level fusion (L5-S1) is safe and carries the benefits of minimal access surgery. Morbidity after multiple level approach is high, and this procedure cannot be advocated at this time.